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1 Apart from chronic migraine, chronic tension-type headache (cTTH) is the most common type seen in primary care.

Cluster headache is the less common, but has characteristic diagnostic features. Other forms of chronic headache are much less common.

2 Sinister headaches are rare in primary care.

Secondary or ‘sinister' headaches arise due to an underlying cause and are rarely seen in primary care. They are mostly seen in patients with an intracranial process, including tumour, haemorrhage, infection or vascular disorders. They may also be associated with systemic infections, the use or overuse of various drugs and head injury.

3 There are six principles of diagnosing chronic headaches.

HIT-6 – a six-item questionnaire – is used to:

1. Exclude sinister headaches.

2. Assess the impact of the headache on the patient's daily activities (high impact).

3. Assess the frequency of the headaches (more than 15 days headache per month).

4. Assess the duration of the chronic headache.

5. Assess the use of headache medications.

6. Screen for the presence of aura symptoms in migraine patients.

It is available online at pulsetoday.co.uk/ downloads.

4 Beware of medication overuse.

Medication overuse headache is seen in about half of all patients with chronic migraine/cTTH. It is associated with overuse of all analgesics, especially codeine-containing drugs, ergots and triptans.

• a long-term history of episodic migraine headaches on more than 15 days a month

• average duration of more than four hours

• chronic migraine or mixed migraine and TTH headaches

• possible medication overuse headache.

Features of cTTH:

• a long-term history of episodic TTH

• occurring on more than 15 days per month

• average duration more than four hours

• chronic TTH headaches

• possible medication overuse headache.

New-onset chronic headaches lasting more than four hours may indicate hemicrania continua or new-daily persistent headache, and patients should be referred.

7 Use a four-pronged approach when selecting treatments for chronic migraine/cTTH.

• Physical therapy and neck exercises for patients with a history of head injury/current neck stiffness

• Withdrawal of overused drugs for patients with medication overuse, with treatment of any withdrawal symptoms

• Introduction of a prophylactic drug to reduce the frequency of attacks

• Strictly rationed use (less than two days a week) of acute medications to treat breakthrough attacks. Successful treatment frequently results in the re-emergence of the episodic headache.

8 Diagnosing cluster headache.

Features of near-daily to several times daily headaches, occurring in clusters, lasting 15-180 minutes, of excruciating intensity and accompanied by red and/or watering eyes and a blocked nose.

Sufferers are usually, but not always men. Headache duration of less than 15 minutes may indicate one of the chronic trigeminal hemicranias such as chronic paroxysmal hemicrania.

9 Selecting treatments for cluster headache.

Prophylaxis is the mainstay of cluster headache management, initiated at the beginning of a new cluster period. Steroids (prednisolone), methysergide and ergotamine are used for short-term prophylaxis and verapamil (gold standard) or lithium for long-term prophylaxis.

Acute treatments are used as rescue medication, when breakthrough attacks occur despite the use of prophylaxis. Subcutaneous sumatriptan 6mg is the gold standard, but nasal spray sumatriptan 20mg and high flow-rate (10l/min) oxygen are also effective.

10 Know when to refer

Referral is indicated when:

• possible sinister headache is suspected

• the diagnosis is uncertain

• patients are resistant to repeated acute and preventive medications.

Dr Andy Dowson is director of the King's Headache Service, King's College Hospital, London

Competing interests: Dr Dowson's unit has received trial funding from NMT Medical and he has received honoraria from AstraZeneca for lectures